How do you Perform the apprehension and Relocation test?
The examination begins with the patient seated:
The examiner palpates the humeral head through the surrounding soft tissue with one hand and guides the patient’s arm with the other hand.
The examiner passively abducts the patient’s shoulder with the elbow flexed and then brings the shoulder into maximum external rotation, keeping the arm in this position.
The test is performed at 60°, 90°, and 120° of abduction to evaluate the superior, medial, and inferior glenohumeral ligaments.
With the guiding hand, the examiner presses the humeral head in an anterior and inferior direction.
The Apprehension and Relocation test can also be performed in the supine position with improved muscular relaxation:
The shoulder lies on the edge of the examining table, which acts as a fulcrum.
In this position the apprehension test can be initiated in various external-rotation and abduction positions.
The healthy shoulder serves for comparison.
What does a positive Apprehension and Relocation mean?
Anterior shoulder pain with reflexive muscle tensing is a sign of an anterior instability syndrome.
The patient has apprehension, the fear that the shoulder will dislocate. Prompted by pain, he or she tries to avoid the examiner’s movement.
Even without pain, however, the tension of the anterior shoulder musculature (pectoralis) alone may be a sign of instability.
Placing the patient supine improves the specificity of the apprehension test.
Jobe Relocation test:
From the apprehension position, the examiner applies a posterior translational stress to the head of the humerus, thereby leading to a sudden decrease in pain and of the fear of dislocation (the humeral head reduces into the socket, and external rotation can be increased).
In a further stage of the apprehension and relocation test, releasing the posteriorly directed pressure causes a sudden increase in pain with the apprehension phenomenon (release test).
Sensitivity & Specificity
A study by Vincent A. Lizzio1 to evaluate the patient with suspected or known anteroinferior glenohumeral instability, he found the Sensitivity and Specificity of the Apprehension test as following:
Sensitivity: 68-88 %
Specificity: 50-100 %
and for Relocation test:
Sensitivity: 57-85 %
Specificity: 87-100 %
When the patient complains of sudden stabbing pain with simultaneous or subsequent paralyzing weakness in the affected extremity, this is referred to as the “dead arm sign.”
It is attributable to the transient compression the subluxated humeral head exerts on the plexus.
It is important to know that at 45° of abduction the test primarily evaluates the medial glenohumeral ligament and the subscapularis tendon.
At or above 90° of abduction, the stabilizing effect of the subscapularis is neutralized and the test primarily evaluates the inferior glenohumeral ligament.
The Apprehension and Relocation test must be performed slowly and carefully to avoid the danger of causing the humeral head to dislocate.
A traumatic anterior instability of the shoulder can lead to injury of the posterior structures. Thus, the clinician must always be aware of potential injuries on the opposite side of the joint even if symptoms are predominantly on one side. In addition, if a joint is hypermobile in one direction, it may be hypomobile in the opposite direction. For example, with anterior instability, the posteroinferior capsule tends to be tight and therefore requires mobilization, whereas the anterior capsule is hypermobile and requires protection.
Vincent A. Lizzio, Fabien Meta, Mohsin Fidai, and Eric C. Makhni. Clinical Evaluation and Physical Exam Findings in Patients with Anterior Shoulder Instability. Curr Rev Musculoskelet Med. 2017 Dec; 10(4): 434–441. PMID: 29043566
Clinical Tests for the Musculoskeletal System 3rd Ed. Book.
Dutton’s Orthopaedic Examination, Evaluation, And Intervention 3rd Edition.